Two professional organizations representing emergency doctors warn that a federal rule released in November could lead to higher out-of-pocket costs for consumers when they need emergency care outside their health plan’s network of providers.

But consumer advocates and health policy analysts say the groups’ proposed solution doesn’t adequately protect consumers.

Under the health law, plans generally can’t charge consumers higher copayments or coinsurance when they visit an emergency department that’s not in their network. So if the plan charges a flat copayment of $500, for example, or coinsurance totaling 30 percent of the cost of services for an emergency department visit at an in-network hospital, it can’t charge consumers more than that rate if they get emergency services at an out-of-network facility. The only plans that are exempt from this provision are those that have grandfathered status under the health law.

However, the law doesn’t prohibit doctors and hospitals from balance billing consumers for out-of-network emergency care if their insurer doesn’t pay the full amount charged. That practice is what really harms consumers, say advocates.

“Our main interest is getting the consumers out of the middle,” says Chuck Bell, programs director at Consumers Union, a consumer advocacy group that has been involved in state efforts to prohibit balance billing. “Even if [the federal government] had written the regulation the way [emergency physicians] advocate, we would likely see balance bills going to consumers.”

Emergency services providers say they are in a tough spot because federal law requires them to treat anyone who comes through their doors, whether or not they have insurance or can afford to pay.

The health law says insurers must pay a “reasonable amount” before a patient can be billed for the rest. The new federal rule defines “reasonable” as the greatest of these three options:

• The median amount negotiated with in-network providers for the emergency service.
• An amount calculated using the same method the plan would generally pay for other out-of-network services.
• The amount paid by Medicare.

The American College of Emergency Physicians and the Emergency Department Practice Management Association maintain that the regulation’s first two options allow insurers to essentially pay whatever they want because their payment data is proprietary. Medicare reimbursement rates are generally lower than those of private plans.

Without a transparent, objective standard in place, the emergency providers say, insurers will pay them less and emergency providers may in turn try to collect the unpaid balance from consumers, unless they live in one of the dozen or so states that prohibit balance billing by out-of-network providers.

The physicians want the payment standard to be “usual and customary charges,” adjusted for geographic variations, using a transparent, independent claims database such as that provided by the nonprofit group Fair Health.

Insurers, however, say providers’ charges are too high and the process by which they are set is often opaque. A study last fall by America’s Health Insurance Plans, a trade group, used Fair Health data to examine the charges billed by out-of-network providers in 2013 and 2014 and compared them to the average fees paid by Medicare in 2014. Analyzing 1.16 million emergency department visits of high severity, the average out-of-network charge was $971 — far higher than the average Medicare payment of $176.

Consumer advocates, such as Bell, and some researchers who have studied consumers’ billing issues, say the government could take a more consumer-friendly approach by eliminating balance billing for emergency care altogether. New York did that with a law that took effect in April. Under that law, insured consumers generally can’t be billed for out-of-network emergency care. (The law doesn’t apply to self-funded companies that pay their employees’ claims directly.)

“It’s promising what New York did,” says Kevin Lucia, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms. “They extract the consumers so they can’t be used as leverage between the providers and insurers.”

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The bills can rack up fast when trying to cure toenail fungus, and it’s not always easy to know which drug to use. Costs can range from over $2,000 for treating one nail to just $10 for a pill that treats all 10 toes but could have bad side effects. Then there are the costly lab tests to confirm that the curling yellow rot chewing through a toenail is in fact mold.

Right now, the most effective treatment for toenail mold or onychomycosis is a pill called terbinafine. It costs about $10 for a full treatment, which can take up to six months. It’s so cheap that it would be more cost-effective to administer the drug to everyone that clinicians think has toenail fungus, rather than spending extra money to confirm the diagnosis in a lab, which can cost up to $148, according to a study published in JAMA Dermatology on Wednesday.

Considering that at least 10 percent of Americans have toe fungus, the health care system could be saving between $18 million and $90 million by skipping the testing, the researchers say.

But some people are reluctant to use terbinafine because there’s a risk of liver damage, a fact that was emphasized when it came on the market decades ago.

“Practitioners were uncomfortable giving it because of the consequences, and we unfairly discouraged a lot of people from taking it,” says Dr. Arash Mostaghimi, a dermatologist at Brigham and Women’s Hospital and Harvard Medical School and senior author on the study. That’s the reason why doctors almost always order lab tests, so that people without a fungal infection wouldn’t be taking that risk.

Dermatologists know now that the chance for liver damage from terbinafine is less than 1 in 100,000, and yet the message persists. “I think that ‘people’ think that terbinafine is dangerous because their primary care doctors and even dermatologists have told them that!” Dr. Matt Kanzler, a dermatologist at Palo Alto Medical Foundation, tells Shots in an email.

Under the influence of this misconception, Kanzler says both physicians and patients elect to use more expensive topical treatments, like a new drug called Jublia that costs thousands of dollars per nail and works about 15 percent of the time. They want to avoid any potential liver injury and malpractice lawsuits. “The problem with this drug is that it isn’t ‘lifesaving’ like cardiac medicine,” he says. “As soon as there are articles mention ‘you should use this safe topical medicine,’ doctors say, ‘I am not going to put myself at risk.'”

The cumulative cost of all these decisions results in a needless burden on the health system, says Ankur Pandya, a health decisions scientist at Harvard University who was not involved with the study. “These extra health care costs are coming from somewhere. Either our tax dollars or our paychecks as we pay more in premiums and deductibles increase. These are dollars that could trickle back into our pockets on a societal level.”

This is part of the reason why health care is so expensive. Insurance premiums hurt, even for cheap plans. The cost to treat even minor nuisances can skyrocket. Then, a toenail fungus is not just a toenail fungus. It becomes an insatiable cash-scarfing beast latched onto the end of your foot. It would be better, Pandya says, to slash procedures that don’t make economic sense.

But other doctors say it’s not that simple. “Just assuming [terbinafine] is safe, [saying] let’s prescribe it for every clinical diagnosis for onychomycosis doesn’t translate perfectly into practice,” says Dr. Chris Adigun, a dermatologist practicing in North Carolina who did not work on the study.

For one, the pills work only about half of the time and must be taken for up to six months, depending on how severe the fungus is, and Adigun says there’s still a 2 percent chance for other side effects. “The incidence of liver injury is low, but [terbinafine] causes stomach upset, taste disturbance, fatigue — it’s often enough that people discontinue the drug.”

Adigun thinks that’s good enough reason to order the lab tests to make sure the patient really does have toenail fungus. “It damages the patient-doctor relationship to go on six months of a systemic drug for something they might not need.”

What’s more, Adigun says, this study doesn’t take into account that the elderly and people with other complications are more likely than healthy people to have toenail fungus. “[These patients] are often on a lot of other medications, so adding terbinafine to the mix without taking that into account is not totally responsible,” she says.

But Mostaghimi thinks it could be irresponsible not to recommend terbinafine as the front-line treatment for toenail fungus. “We’re spending 18 percent of our GDP on health care,” he says. “As a society, when we decide we’re going to spend an additional $80 million of testing for terbinafine, that’s $80 million we’re not spending on things that could be more valuable for us.”

Adigun agrees there’s a significant cost issue, but that doesn’t mean the decision is simple. “The take one for the team mentality is tough when it comes to your health and you’re the one swallowing that pill,” she says. “I think fiscally responsible medicine needs to be ingrained in us.”

At the same time, she says, she took an oath to do no harm. That means doing whatever she can to protect each patient from needless suffering, including side effects from a drug they didn’t need.

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